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460 Recipient Committee Campaign Statement 1-1-15 to 6-30-15Recipient Committee Campaign Statement Cover Page (Government Code Sections 84200 - 84216.5) SEE INSTRUCTIONS ON REVERSE Type or print in ink. Statement covers period from 01/01/2015 through 06/30/2015 1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4. Officeholder, Candidate Controlled Committee ❑ Primarily Formed Ballot Measure Q State Candidate Election Committee Committee 0 Recall Q Controlled (Also Complete Part 5) 0 Sponsored (Also Complete Part 6) ❑ General Purpose Committee Q Sponsored Q Small Contributor Committee 0 Political Party/Central Committee 3. Committee Information ❑ Primarily Formed Candidate/ Officeholder Committee (Also Complete Part 7) I.D. NUMBER 1369332 COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) MC COY FOR COUNCIL 2016, ROBERT STREET ADDRESS (NO P.O. BOX) MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX CITY STATE ZIP CODE AREA CODE /PHONE OPTIONAL: FAX / E -MAIL ADDRESS COVER PAGE Date Stamp X09 NHWI � Date of election if applica 1 of 7 (Month, Day, Year) JUL 1 6 2015 LUJ For Official Use Only 11/08/2016 2. Type of Statement: ❑ Preelection Statement ❑ Quarterly Statement QJ Semi - annual Statement ❑ Special Odd -Year Report ❑ Termination Statement ❑ Supplemental Preelection (Also file a Form 410 Termination) Statement - Attach Form 495 ❑ Amendment (Explain below) Treasurer(s) NAME OF TREASURER Blossom McCoy MAILING ADDRESS NAME OF ASSISTANT TREASURER, IF ANY MAILING ADDRESS CITY STATE ZIP CODE AREA CODE /PHONE OPTIONAL: FAX / E -MAIL ADDRESS 4. Verification I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the information contained herein and in the attached schedules is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on July 14, 2015 Date Executed on July 14, 2015 Date Executed on Date By By By Signature of Controlling Officeholder, Candidate, State Measure Proponent Executed on By Date Signature of Controlling Officeholder, Candidate, State Measure Proponent FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866 /ASK -FPPC (86612753772) State of California Recipient Committee Type or print in ink. COVERPAGE -PART2 Campaign Statement CALIFORNIA FORM MWO Cover Page — Part 2 Page 2 of 7 5. Officeholder or Candidate Controlled Committee 6. Primarily Formed Ballot Measure Committee NAME OF OFFICEHOLDER OR CANDIDATE NAME OF BALLOT MEASURE Robert McCoy OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) BALLOT NO. OR LETTER JURISDICTION ❑ SUPPORT Cupertino City Council ❑ OPPOSE RESIDENTIAUBUSINESS ADDRESS (NO. AND STREET) CITY STATE ZIP Identify the controlling officeholder, candidate, or state measure proponent, if any. NAME OF OFFICEHOLDER NAME OF OFFICEHOLDER, CANDIDATE, OR PROPONENT Related Committees Not Included in this Statement: List any committees HELD not included in this statement that are controlled by you or are primarily formed to receive OFFICE SOUGHT OR HELD DISTRICT NO. IF ANY contributions or make expenditures on behalf of your candidacy. COMMITTEE NAME I.D. NUMBER ^ ❑ SUPPORT NAME OF TREASURER CONTROLLED COMMITTEE? 7. Primarily Formed Candidate /Officeholder Committee List names of officeholder(s) or candidate(s) for which this committee is primarily formed. ❑ YES ❑ NO NAME OF OFFICEHOLDER COMMITTEE ADDRESS STREETADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE /PHONE COMMITTEE NAME I.D. NUMBER NAME OF TREASURER CONTROLLED COMMITTEE? ❑ YES ❑ NO COMMITTEE ADDRESS STREETADDRESS (NO P.O. BOX) NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD ❑ SUPPORT ❑ OPPOSE CITY STATE ZIP CODE AREA CODE /PHONE Attach continuation sheets if necessary FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/2753772) State of California Campaign Disclosure Statement Type or print in ink. Amounts may be rounded Summary Page to Whole dollars. Statement covers period from 01/01/2015 SUMMARYPAGE SEE INSTRUCTIONS ON REVERSE 6. Payments Made ........................ ............................... Schedule E, Line 4 $ through 06/30/2015 page 3 of 7 NAME OF FILER Add Lines 6 + 7 $ 9. Accrued Expenses (Unpaid Bills) ............................... Schedule F, Line 3 10. Nonmonetary Adjustment ........... ............................... Schedule C, Line 3 MC COY FOR COUNCIL 2016, ROBERT Add Lines 8 + 9 + 10 $ 668.87 16. ENDING CASH BALANCE .......... Add Lines 12 + 13 + 14, then subtract Line 15 I.D. NUMBER 1545.33 If this is a termination statement, Line 16 must be zero. 1369332 Contributions Received 0.00 Column A Column B Calendar Year Summary for Candidates 18. Cash Equivalents ......... ............................... See instructions on reverse $ TOTALTHIS PERIOD (FROM ATTACHEDSCHEDULES) CALENDAR YEAR TOTALTO DATE Running in Both the State Primary and 1. Monetary Contributions ............ ............................... Schedule A, Line 3 $ 5000.00 $ General Elections 2. Loans Received ....................... ............................... schedule B, Line 3 - 3500.00 1/1 through 6/30 7/1 to Date 3. SUBTOTAL CASH CONTRIBUTIONS ......................... Add Lines 1 +2 $ 1500.00 $ 20. Contributions 4. Nonmonetary Contributions ..... ............................... schedule c, Line 3 0.00 Received $ $ 21. Expenditures 5. TOTAL CONTRIBUTIONS RECEIVED • ...... ....................AddLines3 +4 $ 1500.00 $ Made $ $ Expenditures Made 6. Payments Made ........................ ............................... Schedule E, Line 4 $ 7. Loans Made .............................. ............................... Schedule H, Line 3 8. SUBTOTALCASH PAYMENTS ..... ............................... Add Lines 6 + 7 $ 9. Accrued Expenses (Unpaid Bills) ............................... Schedule F, Line 3 10. Nonmonetary Adjustment ........... ............................... Schedule C, Line 3 11. TOTAL EXPENDITURES MADE . ............................... Add Lines 8 + 9 + 10 $ 668.87 $ 0.00 668.87 $ 0.00 0.00 668.87 $ Current Cash Statement 12. Beginning Cash Balance ....................... Previous summary Page, Line 16 $ 307.20 13. Cash Receipts .................... ............................... Column A, Line 3 above 1500.00 14. Miscellaneous Increases to Cash ........................... Schedule t, Line 4 407.00 15. Cash Payments ................... ............................... Column A, Line 8 above 668.87 16. ENDING CASH BALANCE .......... Add Lines 12 + 13 + 14, then subtract Line 15 $ 1545.33 If this is a termination statement, Line 16 must be zero. 17. LOAN GUARANTEES RECEIVED ........................... Schedule B, Part 2 $ 0.00 Cash Equivalents and Outstanding Debts 18. Cash Equivalents ......... ............................... See instructions on reverse $ 0.00 19. Outstanding Debts ......................... Add Line 2 +Line 9 in Column B above $ 0.00 To calculate Column B, add amounts in Column A to the corresponding amounts from Column B of your last report. Some amounts in Column A may be negative figures that should be subtracted from previous period amounts. If this is the first report being filed for this calendar year, only carry over the amounts from Lines 2, 7, and 9 (if any). Expenditure Limit Summary for State Candidates 22. Cumulative Expenditures Made" (If Subject to Voluntary Expenditure Limit) Date of Election Total to Date (mm /dd /yy) /J $ "Amounts in this section may be different from amounts reported in Column B. FPPC Form 460 (January /05) FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 ,3772) Schedule A Type or print in ink. SCHEDULE A ivionetary CoontriDutionS Kecelved " "'�to ole of "' " " "C" to whole dollars. Statement covers period 01/01/2015 CALIFORNIA � • , from FORM SEE INSTRUCTIONS ON REVERSE through 06/30/2015 Page 4 of 7 NAME OF FILER M C COY FOR COUNCIL 2016, ROBERT I.D. NUMBER 136NUMB DATE FULL NAME, STREET ADDRESS AND ZIP CODE OF CONTRIBUTOR CONTRIBUTOR IF AN INDIVIDUAL, ENTER AMOUNT CUMULATIVE TO DATE PER ELECTION RECEIVED (IF COMMITTEE, ALSO ENTER I.D.NUMBER) CODE * OCCUPATION AND EMPLOYER RECEIVED THIS CALENDAR YEAR TO DATE (IF SELF - EMPLOYED, ENTER NAME OF BUSINESS) PERIOD (JAN.1 -DEC. 31) (IF REQUIRED) Yvonne Mei ® IND 01/25/2015 ❑ PTY ❑SCC ❑IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑IND ❑ COM ❑ OTH ❑ PTY ❑ SCC ❑IND ❑ COM ❑ OTH ❑ PTY ❑ SCC SUBTOTAL $ 5000 00 Schedule A Summary 1. Amount received this period — itemized monetary contributions. (Include all Schedule A subtotals.) ........................ ............................... 2. Amount received this period — unitemized monetary contributions of less than $100 3. Total monetary contributions received this period. (Add Lines 1 and 2. Enter here and on the Summary Page, Column A, Line 1.) ...... $ 5000.00 ...... TOTAL $ 0 5000.00 *Contributor Codes IND— Individual COM — Recipient Committee (other than PTY or SCC) OTH — Other (e.g., business entity) PTY — Political Party SCC —Small Contributor Committee FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772) Q..L....1..1.. In n_-i w Tvne nr nrin4 in inir SCHFni)I FR -PART1 V V*�VMM�V � - - -I GIL I Amounts may be rounded Statement covers period Loans Received to Whole dollars. CALIFORNIA . ' 01/01/2015 from • . SEE INSTRUCTIONS ON REVERSE through 06/30/2015 Page 5 of 7 NAME OF FILER I.D. NUMBER MC COY FOR COUNCIL 2016, ROBERT 1369332 FULL NAME, STREET ADDRESS AND ZIP CODE IF AN INDIVIDUAL, ENTER OUTSTANDING (b) AMOUNT (c) (d) OUTSTANDING (e) (9) OF LENDER OCCUPATION AND EMPLOYER BALANCE RECEIVED THIS AMOUNTPAID BALANCEAT INTEREST ORIGINAL CUMULATIVE (IF COMMITTEE, ALSO ENTER LD. NUMBER) ( IF SELF - EMPLOYED, ENTER NAMEOFBUSINESS) BEGINNING THIS PERIOD OR FORGIVEN CLOSE OF THIS PAID THIS AMOUNT OF CONTRIBUTIONS PERIOD THIS PERIOD* PERIOD PERIOD LOAN TO DATE Blossom McCoy Manager L7J PAID CALENDARYEAR % $ ❑ FORGIVEN RATE PERELECTION ** 3500.00 tw IND El COM El OTH ❑ PTY F-1 SCC $ $ $ $ DATE DUE DATE INCURRED $ ❑ PAID CALENDARYEAR ❑ FORGIVEN PER ELECTION ** RATE ❑ IND ❑ COM ❑ OTH ❑ PTY ❑ SCC DATE DUE DATE INCURRED ❑ PAID CALENDAR YEAR ❑ FORGIVEN PER ELECTION** RATE t❑ IND ❑ COM ❑ OTH ❑ PTY ❑SCC $ $ $ $ $ DATE DUE DATE INCURRED SUBTOTALS $ 0 $ 3500.00 $ 0 $ Schedule B Summary 1. Loans received this period .......................................... ............................... (Total Column (b) plus unitemized loans of less than $100.) 2. Loans paid or forgiven this period ............................... ............................... (Total Column (c) plus loans under $100 paid or forgiven.) (Include loans paid by a third party that are also itemized on Schedule A.) 3. Net change this period. (Subtract Line 2 from Line 1.) .............. Enter the net here and on the Summary Page, Column A, Line 2. *Amounts forgiven or paid by another party also must be reported on Schedule A. ** If required. 0 3500.00 NET $ -3500.00 (May be a negative number) (Enter (e) on Schedule E, Line 3) tContributor Codes IND— Individual COM — Recipient Committee (other than PTY or SCC) OTH — Other (e.g., business entity) PTY — Political Party SCC — Small Contributor Committee FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866 1ASK -FPPC (8661275 -3772) Schedule E Payments Made Type or print in ink. Amounts may be rounded to whole dollars. Statement covers period from 01/01/2015 SEE INSTRUCTIONS ON REVERSE through 06/30/2015 page 6 of 7 NAME OF FILER I.D. NUMBER MC COY FOR COUNCIL 2016, ROBERT 1369332 E CODES: If one of the following codes accurately describes the payment, you may enter the code. Otherwise, describe the payment. CMP CNS campaign paraphernalia /misc. MBR member communications RAID radio airtime and production costs CTB campaign consultants contribution (explain nonmonetary)" MTG meetings and appearances RFD returned contributions CVC civic donations OFC office expenses SAL campaign workers' salaries FIL candidate filing /ballot fees PEr PHO petition circulating phone banks TEL t.v. or cable airtime and production costs FND fundraising events POL polling and survey research TRC TRS candidate travel, lodging, and meals staff /spouse travel, lodging, and meals IND LEG independent expenditure supporting /opposing others (explain)' legal defense POS postage, delivery and messenger services TSF transfer between committees of the same candidate /sponsor LIT campaign literature and mailings PRO PRT professional services (legal, accounting) ads VOT voter registration print 1NEB information technology costs (internet, e-mail) NAME AND ADDRESS OF PAYEE (IFCOMMITTEE, ALSOENTER I.D. NUMBER) CODE OR DESCRIPTION OF PAYMENT AMOUNTPAID Target 588.87 Bank of America Service Fees ` Payments that are contributions or independent expenditures must also be summarized on Schedule D. SUBTOTAL$ 668.87 Schedule E Summary 1. Itemized payments made this period. (Include all Schedule E subtotals.) 668.87 2. Unitemized payments made this period of under $100 ........................................................................................................... ............................... $ 0 3. Total interest paid this period on loans. (Enter amount from Schedule B, Part 1, Column (e).) ................................................ ............................... $ 0 4. Total payments made this period. (Add Lines 1, 2, and 3. Enter here and on the Summary Page, Column A, Line 6.) ............................. TOTAL $ 668.87 FPPC Form 460 (January/05) FPPC Toll -Free Helpline: 866 1ASK -FPPC (8661275 -3772) Schedule I Tvne nr nrint in ink Qr1WCnI n c iviisceiianeous increases to Cash Amounts maybe rounded Statement covers period to whole dollars. CALIFORNIA ' I from 01/01/2015 • FORM SEE INSTRUCTIONS ON REVERSE through 06/30/2015 Page 7 of 7 NAME OF FILER I.D. NUMBER MC COY FOR COUNCIL 2016, ROBERT 1369332 DATE RECEIVED FULL NAME AND ADDRESS OF SOURCE (IFCOMMITTEE, ALSOENTER I.D. NUMBER) DESCRIPTION OF RECEIPT INCREASE TO CASH City of Cupertino City Council Candidate Statement 02/03/2015 Attach additional information on appropriately labeled continuation sheets. SUBTOTAL $ 407.00 Schedule I Summary 1. Itemized increases to cash this period ......................................................................................... ............................... $ 407.00 2. Unitemized increases to cash of under $100 this period .............................................................. ............................... $ 0 3. Total of all interest received this period on loans made to others. (Schedule H, Column (e).) .. ............................... $ 0 4. Total miscellaneous increases to cash this period. (Add Lines 1, 2, and 3. Enter here and on the SummaryPage, Line 14.) ............................................................................................ ............................... TOTAL $ 407.00 FPPC Form 460 (January /05) FPPC Toll -Free Helpline: 866 /ASK -FPPC (86612753772)